Chapter 10: Telepsychiatry

CASE STUDY

A psychiatrist is providing a weekly telepsychiatry clinic for a small rural community mental health center in the intermountain west. She evaluates a new patient, John a 74-year old recently widowed rancher whose children have brought him out of their concern of his increasing isolation. John reports that since his wife passed three months ago he has been having difficulty sleeping, leading to increasing fatigued during the day. He has lost his appetite and motivation to engage in ranch work or socialize with others. Although he denies current or history of suicidality, he feels that he has no reason to go on living and has access to firearms at home. The psychiatrist works with the clinic's onsite social worker to develop a treatment plan, which includes an antidepressant and sleep medication along with grief-focused supportive therapy. The psychiatrist educates John and his adult children about depression and loss and engages in a candid discussion about firearm safety in the context of a depressive episode and risks for suicide. The family agrees until the depression has resolved to hold John's firearms for him. Over the next 8 to 12 weeks through medication management and therapy John's depression begins to resolve, with the psychiatrist following John's progress in their follow-up video sessions and through contact with the clinic's social worker.

INTRODUCTION

Technological advances have led to significant changes in psychiatric service delivery models. ¹ As broadband and wireless Internet access become widely available, and smart phones, tablets, and other small, portable devices allow convenient, mobile access to the Internet, virtual care options are expanding. These virtual options have emerged not only because of improved technological ability, but also because of an increasing recognition of the need to maximize the ability of a limited number of psychiatric providers to serve a larger patient population; a growing consumer demand for patient-centered, convenient care options; and payor demand for more cost-effective care. ² The American Medical Association (AMA) aptly notes that “[i]nnovation in technology, including information technology, is redefining how people perceive time and distance. It is reshaping how individuals interact with and relate to others, including when, where, and how patients and physicians engage with one another.” ³ Virtual modalities lend themselves particularly well to the field of psychiatry where providers need no peripheral devices or instruments for patient assessment or treatment. Through an increasingly diverse set of modalities and treatment models, telepsychiatry—defined broadly as leveraging audio and video technology to provide services from a distance ⁴ —is changing the nature of the traditional psychiatrist–patient relationship to a collaborative experience. This chapter is designed to describe the current treatment modalities and models that support the evolving practice, summarize the evidence for efficacy, and provide an overview of the pragmatic considerations related to telepsychiatry implementation across a variety of care settings.

MODALITIES/MODELS

Telepsychiatry uses two primary service delivery modalities, real time, also ...